Provider Demographics
NPI:1508849183
Name:SCOTT, MARVETTA A (MD)
Entity Type:Individual
Prefix:
First Name:MARVETTA
Middle Name:A
Last Name:SCOTT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8300 DOUGLAS AVE STE 800
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75225-5826
Mailing Address - Country:US
Mailing Address - Phone:817-381-6813
Mailing Address - Fax:
Practice Address - Street 1:8300 DOUGLAS AVE STE 800
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75225-5826
Practice Address - Country:US
Practice Address - Phone:817-381-6813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-28
Last Update Date:2022-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP7980207R00000X
GA54663208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAI24675Medicare UPIN
GAI24675Medicare UPIN